3. Who Treats 32 Million Patients?
With 32 million Americans gaining health care coverage in the coming years — and demanding services as a consequence — the next challenge is addressing the supply side of the equation. Once these folks start putting their freshly minted insurance cards to use, who will actually perform the blood-pressure checks, treat the cancers and monitor the diabetes? Family physicians, who are on the front lines of this surge in demand, are already in short supply, as are nurses, whom the new law identifies as critical players in meeting some of the expected new demand for services. By 2020, when most of the currently uninsured will have been fully brought into the health care system, the American Academy of Family Physicians predicts a shortfall of 40,000 in the ranks of primary-care providers to treat them.
One way to address that gap would be to make primary-care medicine a more attractive field — not just for physicians but also for nurse practitioners who receive an additional one to two years of training to expand their range of care into areas like anesthesia. The new law calls for appropriations over five years to fund further training programs, scholarships and loan repayments for those entering primary care. But even if new students take up those offers this year, they won't be ready to treat patients for three to seven years. The law would also temporarily boost what primary-care providers receive for treating patients insured by Medicaid, the plan that will pick up nearly half of the newly covered.
In the long run, addressing the shortage of primary-care providers will take much more than money. "What is clear to me is that we cannot fix the problem by adding 32 million people to the mix and not changing the way we deliver care," says Susan DeVore, president and CEO of Premier Healthcare Alliance, a coalition of 2,300 not-for-profit hospitals dedicated to improving health care performance.
So what would fix the problem? Ideally, policy should address not just the question of who delivers care but also how and where services are provided. The new law, for example, recognizes that doctors can't be the only ones to provide care and that hospitals and physicians' offices can't be the only places where people receive health services. The law is expected to ultimately spend $11 billion to create more health centers based in communities and schools as well as nurse-managed clinics. It will also enhance the government-salaried National Health Service Corps of primary-care physicians, nurse practitioners and physician's assistants who target underserved regions and receive loan repayments or scholarships to subsidize their medical education.
The funding will also support programs like the "medical home," a team-based approach to delivering health care that breaks down the traditional hierarchy in which all health decisions are made by the physician. Instead, a medical home disperses responsibility across a range of providers and facilities, which allows existing hospitals and clinics to accommodate the increased demand for services without costly investments in capacity building.
The medical-home concept is already being tested in many markets for just this reason. In New Jersey, for example, AtlantiCare's pilot Special Care Center, a medical-home program collaborating with Atlantic City's largest hotel and restaurant union, is successfully reducing ER visits and hospital admissions. Two family physicians work with a nurse practitioner, and together the team discusses the best ways to treat those with chronic conditions such as diabetes and heart disease. Patients receive no claims forms or bills for services at the center, and salaried providers are not reimbursed on the basis of the volume of services they generate, so they can focus on providing appropriate, quality care. "The doctors and patients in the center are outside of what I call the tyranny of the visit," says Dr. Katherine Schneider, vice president of health engagement at AtlantiCare.
Making this shift on a national level, however, won't be easy. Even innovative health-system administrators acknowledge that as long as the fee-for-service reimbursement structure remains in place with private insurers, doctors will be forced to practice two kinds of medicine: one in which they are reimbursed on the basis of the volume of services they provide and another in which the health outcomes and efficiency of their care are prioritized. And as long as patients still view health care as an only-when-I'm-sick endeavor, costs will continue to rise. When Massachusetts subsidized health care coverage in 2006 and mandated universal coverage by 2007, visits to the state's emergency rooms swelled 7%, adding to a $146 million jump in health care costs from 2005 to 2006.
Massachusetts' experience highlights how much of our health behavior is ingrained in the current fee-for-service system — which, for the time being, isn't going away. The key to achieving real reform within the constraints of that reality will rest on persuading new — and existing — patients to seek care to maintain their health rather than to treat a disease after it has taken hold. If all goes according to plan, the bill's greatest achievement may be to make it possible for more people to access the health system in many different ways. Health care will increasingly take the form of preventive services such as regular diabetes checkups and weight-loss programs, instead of patients waiting to see their doctors until they need coronary-bypass operations or kidney dialysis. Those who are currently uninsured may turn out to be at the forefront of this trend, since 55% of them are under the age of 35, according to the Rand Corp. Traditionally, this group tends to be the healthiest segment of the population and uses health care the least. That makes it the ideal cohort to begin thinking of health care providers as wellness coaches rather than as emergency SWAT teams.